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IDPW







Health Certificate for COVID-19 Name (First, Last) Gender Age y/o Date of Birth (dd/mm/yyyy) Nationality Passport No.
1) Date of Examination (dd/mm/yyyy) / /
2) Close contact with a person with COVID-19 (probable or confirmed) while they were ill without taking appropriate precautionary measures within the last two weeks.
YES / NO
3) Clinical symptoms such as cough, shortness of breath, chills, fatigue, muscle pain, headache, sore throat, vomiting, diarrhea, or new loss of taste or smell.
YES / NO
Others:
5) Testing for COVID-19 (examined on the same day as the examination)
Sample Testing for COVID-19 Laboratory result
Nasopharyngeal swab
Nucleic acid amplification test (LAMP)
Antigen test (CLEIA)
Negative ( Not detected )
*Sample Date (dd/mm/yyyy);
Based on the above information, the person named above is currently healthy and
unlikely infected with SARS-CoV-2. Therefore, he or she is fit for flight/work at the current
health condition.
Date of Issue (dd/mm/yyyy) Signature of Physician Name of Physician(Printed)